IM Sub-I: Untrustworthy patients

Yesterday I spent my morning shopping at the outlets at Round Rock (picked up a suit for interviews), and spent part of the evening browsing through the Domain (an upscale outdoor shopping center on Braker Lane; there's even live music at night) while chatting with Dina on the phone. Then I watched the Olympics in time to see Michael Phelps earn his 8th gold medal; talk about awesome =)

This morning Greg and An had the day off, so it was just me, Zack, and Yan along with Dr. N, our attending of the weekend. Dr. N certainly seemed nice enough; even pimped me on a few topics that were mostly hit or miss. My diabetic noncompliant patient was causing trouble for the nurses again; he kept insisting that he needed to go home because he's supposed to get a motorized wheelchair delivered to his house and he needs to be there to sign for it. "Just give me oral antibiotics," he said, even though Yan tried to explain that pills alone weren't strong enough to treat his osteomyelitis (he needs IV meds). Once we assured him that he could leave AMA with antibiotics, he seemed happy, but then he privately called Yan back to his room and asked for some Norco for his leg pain. Dr. N said that Yan could write him a prescription for 5 Norco, but no more than that. After we left the 4th floor and went to Obs to see 2 patients, Yan got paged twice regarding our noncompliant patient. Apparently he was refusing to sign the AMA form unless he got his Norco prescription. So Yan went in to "negotiate" with him about how much Norco he could get (he kept asking why he couldn't get at least twenty). I stood outside the room eavesdropping on their conversation (I didn't know why I had to be present; I could have gone to other floors to help Zack or something), but I wasn't the only one. Two nurses told me that the patient had never once complained of pain while he was in the hospital, and since he's not taking Norco right now, there's no need to start him on it as an outpatient. "You know what he's going to do with that Norco? He's going to sell it on the streets," said one nurse. "The PICC nurse has seen him on 6th street; he probably wants the Norco so he can make some money, and when he runs out, he'll come right back." Another nurse agreed that he was a tough patient to handle, adding that he's been "stewing" in his urine for almost twelve hours because every time a nurse approached him to change his sheets, he'd get mad and refuse to get cleaned. He's also refusing to get antibiotics (hence, the reason for letting him go AMA), except now he won't leave without Norco. Finally Danielle, one of the nurses, couldn't stand it anymore and asked me to call Yan out, pretending that she had an important phone call. Yan, just like me, had bought into our patient's claim that he was hurting, but its the nurses who spend more hours on the floors near him that know what's going on. Yan didn't know what the policy was for leaving AMA, so we asked another nurse to talk to the patient. He repeated the same story that he needed to be home to accept his wheelchair or else he won't get another one for five years (I've personally never heard of such a thing), but she called his bluff and said that her father was hospitalized once but still got a motorized wheelchair before he left. "Fine, I'll stay here and get the PICC and miss out on the wheelchair," he said angrily, so the nurses left the room thinking that things were settled. Then all hell broke loose as he began screaming and cursing at no one in particular, then throwing things against the wall (someone had to call a Code Gray on him and security came to get him to calm down). Then he started yelling about how no one's cleaned him in hours, and the other nurses were like, "Oh, hell no, he didn't!" (b/c he was the one who had refused to get cleaned and said he'd stay and make everyone's life hell). "Now's he's going to say we neglected him," one nurse grumbled. Earlier in the day, Yan had commented that she doesn't know whether she can trust what patients say anymore. About a week ago, we had a patient who came in with multiple bullae on his left hand that eventually coalesed to form one huge bulla that covered his entire left hand. He claimed he didn't know what happened, that he "woke up" after passing out on his porch and found his hand swollen, then later said he may have scratched himself on the nail. Fearing a bacterial infection (especially since we had no idea what we were dealing with) and compartment syndrome, plastic surgery came to do a fasciotomy on his hand. Then yesterday, his father called the hospital saying that he had seen a copperhead bite our patient's hand. Ummm, what?! Why didn't anyone tell us this earlier? The patient had continually denied that he'd been bitten by a snake b/c he didn't know what had happened, but once Yan showed him an article about snake bites, including an image of a person with multiple bullae on his hand (very similar to his initial presentation), he said, "Yeah, that's exactly what it looked like!" *sigh* Now that we know he doesn't have a bacterial infection, I think we can d/c his antibiotics. After work, I went to the Town Lake Trail and walked/jogged at least 3-4 miles by walking from Lamar Blvd to Mopac, round trip. Needless to say I was exhausted by the time I got back to my car.